What factors are associated with ambulance use for non-emergency problems in children?:A systematic mapping review and qualitative synthesis

Objective To explore what factors are associated with ambulance use for non-emergency problems in children. Methods This study is a systematic mapping review and qualitative synthesis of published journal articles and grey literature. Searches were conducted on the following databases, for articles published between January 1980 and July 2020: MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. A Google Scholar and a Web of Science search were undertaken to identify reports or proceedings not indexed in the above. Book chapters and theses were searched via the OpenSigle, EThOS and DART databases. A literature advisory group, including experts in the field, were contacted for relevant grey literature and unpublished reports. The inclusion criteria incorporated articles published in the English language reporting findings for the reasons behind why there are so many calls to the ambulance service for non-urgent problems in children. Data extraction was divided into two stages: extraction of data to generate a broad systematic literature € map', and extraction of data from highly relevant papers using qualitative methods to undertake a focused qualitative synthesis. An initial table of themes associated with reasons for non-emergency calls to the ambulance for children formed the € thematic map' element. The uniting feature running through all of the identified themes was the determination of € inappropriateness' or € appropriateness' of an ambulance call out, which was then adopted as the concept of focus for our qualitative synthesis. Results There were 27 articles used in the systematic mapping review and 17 in the qualitative synthesis stage of the review. Four themes were developed in the systematic mapping stage: socioeconomic status/geographical location, practical reasons, fear of consequences and parental education. Three analytical themes were developed in the qualitative synthesis stage including practicalities and logistics of obtaining care, arbitrary scoring system and retrospection. Conclusions There is a lack of public and caregiver understanding about the use of ambulances for paediatrics. There are factors that appear specific to choosing ambulance care for children that are not so prominent in adults (fever, reassurance, fear of consequences). Future areas for attention to decrease ambulance activation for paediatric low-acuity reports were highlighted as: identifying strategies for helping caregivers to mitigate perceived risk, increasing availability of primary care, targeted education to particular geographical areas, education to first-time parents with infants and providing alternate means of transportation. PROSPERO registration number CRD42019160395

Q-Dependent Susceptibilities in Ferromagnetic Quasiperiodic Z-Invariant Ising Models

We study the q-dependent susceptibility chi(q) of a series of quasiperiodic Ising models on the square lattice. Several different kinds of aperiodic sequences of couplings are studied, including the Fibonacci and silver-mean sequences. Some identities and theorems are generalized and simpler derivations are presented. We find that the q-dependent susceptibilities are periodic, with the commensurate peaks of chi(q) located at the same positions as for the regular Ising models. Hence, incommensurate everywhere-dense peaks can only occur in cases with mixed ferromagnetic-antiferromagnetic interactions or if the underlying lattice is aperiodic. For mixed-interaction models the positions of the peaks depend strongly on the aperiodic sequence chosen.Comment: LaTeX2e, 26 pages, 9 figures (27 eps files). v2: Misprints correcte

The Chiral Potts Models Revisited

In honor of Onsager's ninetieth birthday, we like to review some exact results obtained so far in the chiral Potts models and to translate these results into language more transparent to physicists, so that experts in Monte Carlo calculations, high and low temperature expansions, and various other methods, can use them. We shall pay special attention to the interfacial tension $\epsilon_r$ between the $k$ state and the $k-r$ state. By examining the ground states, it is seen that the integrable line ends at a superwetting point, on which the relation $\epsilon_r=r\epsilon_1$ is satisfied, so that it is energetically neutral to have one interface or more. We present also some partial results on the meaning of the integrable line for low temperatures where it lives in the non-wet regime. We make Baxter's exact results more explicit for the symmetric case. By performing a Bethe Ansatz calculation with open boundary conditions we confirm a dilogarithm identity for the low-temperature expansion which may be new. We propose a new model for numerical studies. This model has only two variables and exhibits commensurate and incommensurate phase transitions and wetting transitions near zero temperature. It appears to be not integrable, except at one point, and at each temperature there is a point, where it is almost identical with the integrable chiral Potts model.Comment: J. Stat. Phys., LaTeX using psbox.tex and AMS fonts, 69 pages, 30 figure

Options for managing alkaline steel slag leachate: A life cycle assessment

Management of steel slag (a major by-product of the steel industry) includes the treatment of highly alkaline leachate (pH > 11.5) from rainwater infiltration of slag deposits to prevent adverse impact upon surface or ground waters. This study aims to compare different treatment options for steel slag leachate through a life cycle assessment (LCA). Five options were compared: active treatment by acid dosing (A-H2SO4), active treatment by carbon dioxide dosing (A-CO2), active treatment by calcium chloride dosing (A-CaCl2), passive treatment by cascade and reedbeds with pumping (P-P), and passive treatment by cascade and reedbeds in a gravity-driven configuration (P-G). The functional unit was 1 m3 of treated leachate with pH < 9, considering 24 h and 365 days of operating, maintenance operations every year, and service life of 20 years. Inventory data were obtained from project designers, commercial suppliers, laboratory data and field tests. The environmental impacts were calculated in OpenLCA using the ELCD database and ILCD 2011 method, covering twelve impact categories. The A-CaCl2 option scored worse than all other treatments for all considered environmental impact categories. Regarding human toxicity, A-CaCl2 impact was 1260 times higher than the lowest impact option (A-CO2) for carcinogenics and 53 times higher for non-carcinogenics (A-H2SO4). For climate change, the lowest impact was calculated for P-G < P-P < A-H2SO4 < A-CO2 < A-CaCl2, while for particulate matter/respiratory inorganics, the options ranked as follows P-G < P-P < A-CO2 < A-H2SO4 < A-CaCl2. The major contributor to these impact categories was the Solvay process to produce CaCl2. Higher uncertainty was associated with the categories particulate matter formation, climate change and human toxicity, as they are driven by indirect emissions from electricity and chemicals production. Both passive treatment options had better environmental performance than the active treatment options. Potential design measures to enhance environmental performance of the treatments regarding metal removal and recovery are discussed and could inform operational management at active and legacy steel slag disposal sites

How parents and children evaluate emollients for childhood eczema: a qualitative study

BACKGROUND: Eczema affects one in five children in the UK. Regular application of emollients is routinely recommended for children with eczema. There are four main emollient types, but no clear evidence of which is best. The current ‘trial and error’ approach to find suitable emollients can be frustrating for parents, children, and clinicians. AIM: To identify how parents and children experience and evaluate emollients. DESIGN AND SETTING: Qualitative interview study, nested within a primary care trial of emollients (Best Emollients for Eczema [BEE] trial). METHOD: Semi-structured interviews with children with eczema and their parents were conducted. Participants were purposively sampled on emollient type (lotion, cream, gel, or ointment), age, and eczema severity. RESULTS: Forty-four parents were interviewed, with children participating in 24 of those interviews. There was no clear preference for any one emollient type. The strongest theme was the variation of experience in each of the four types. Participants focused on thickness and absorbency, both positively and negatively, to frame their evaluations. Effectiveness and acceptability were both considered when evaluating an emollient but effectiveness was the primary driver for continued use. For some, participating in the trial had changed their knowledge and behaviour of emollients, resulting in use that was more regular and for a longer duration. CONCLUSION: There is no one emollient that is suitable for everyone, and parents/children prioritise different aspects of emollients. Future research could evaluate decision aids and/or tester pots of different types, which could enable clinicians and parents/children to work collaboratively to identify the best emollient for them

A feasibility study of implementing grip strength measurement into routine hospital practice (GRImP): study protocol.

BACKGROUND: Handgrip strength is a non-invasive marker of muscle strength, and low grip strength in hospital inpatients is associated with poor healthcare outcomes including longer length of stay, increased functional limitations, and mortality. Measuring grip strength is simple and inexpensive. However, grip strength measurement is not routinely used in clinical practice. The aim of this study is to evaluate the feasibility of implementing grip strength measurement into routine clinical practice. METHODS/DESIGN: This feasibility study is a mixed methods design combining qualitative, quantitative, and economic elements and is based on the acute medical wards for older people in one hospital. The study consists of three phases: phase 1 will define current baseline practice for the identification of inpatients at high risk of poor healthcare outcomes, their nutrition, and mobility care through interviews and focus groups with staff as well as a review of patients' clinical records. Phase 2 will focus on the feasibility of developing and implementing a training programme using Normalisation Process Theory to enable nursing and medical staff to measure and interpret grip strength values. Following the training, grip strength will be measured routinely for older patients as part of admission procedures with the use of a care plan for those with low grip strength. Finally, phase 3 will evaluate the acceptability of grip strength measurement, its adoption, coverage, and basic costs using interviews and focus groups with staff and patients, and re-examination of clinical records. DISCUSSION: The results of this study will inform the translation of grip strength measurement from a research tool into clinical practice to improve the identification of older inpatients at risk of poor healthcare outcomes. TRIAL REGISTRATION: Clinicaltrials.gov NCTO2447445

Implementation of grip strength measurement in medicine for older people wards as part of routine admission assessment: identifying facilitators and barriers using a theory-led intervention.

BACKGROUND: Low grip strength in older inpatients is associated with poor healthcare outcomes including longer length of stay and mortality. Measuring grip strength is simple and inexpensive. However, it is not routinely used in clinical practice. We aimed to evaluate the implementation of grip strength measurement into routine clinical practice. METHODS: This implementation study was a mixed methods study based in five acute medical wards for older people in one UK hospital. Intervention design and implementation evaluation were based on Normalization Process Theory (NPT). A training program was developed and delivered to enable staff to measure grip strength and use a care plan for patients with low grip strength. Routine implementation and monitoring was assessed using the "implementation outcome variables" proposed by WHO: adoption, coverage, acceptability, fidelity, and costs analysis. Enablers and barriers of implementation were identified. RESULTS: One hundred fifty-five nursing staff were trained, 63% in just 3 weeks. Adoption and monthly coverage of grip strength measurement varied between 25 and 80% patients across wards. 81% of female patients and 75% of male patients assessed had low grip strength (< 27 kg for men and < 16 kg for women). Staff and patients found grip measurement easy, cheap and potentially beneficial in identifying high-risk patients. The total cost of implementation across five wards over 12 months was less than £2302. Using NPT, interviews identified enablers and barriers. Enablers included: highly motivated ward champions, managerial support, engagement strategies, shared commitment, and integration into staff and ward daily routines. Barriers included lack of managerial and staff support, and high turnover of staff, managers and champions. CONCLUSIONS: Training a large number of nurses to routinely implement grip strength measurement of older patients was feasible, acceptable and inexpensive. Champions' motivation, managerial support, and shared staff commitment were important for the uptake and normalisation of grip strength measurement. A high percentage of older patients were identified to be at risk of poor healthcare outcomes and would benefit from nutritional and exercise interventions. Measuring grip strength in these patients could provide an opportunity to identify those with normal grip strength for fast tracking through admission to discharge thereby reducing length of stay. TRIAL REGISTRATION: Clinicaltrials.gov NCTO2447445 . Registered May 18, 2015

Can routine clinical data identify older patients at risk of poor healthcare outcomes on admission to hospital?

OBJECTIVE: Older patients who are at risk of poor healthcare outcomes should be recognised early during hospital admission to allow appropriate interventions. It is unclear whether routinely collected data can identify high-risk patients. The aim of this study was to define current practice with regard to the identification of older patients at high risk of poor healthcare outcomes on admission to hospital. RESULTS: Interviews/focus groups were conducted to establish the views of 22 healthcare staff across five acute medicine for older people wards in one hospital including seven nurses, four dieticians, seven doctors, and four therapists. In addition, a random sample of 60 patients' clinical records were reviewed to characterise the older patients, identify risk assessments performed routinely on admission, and describe usual care. We found that staff relied on their clinical judgment to identify high risk patients which was influenced by a number of factors such as reasons for admission, staff familiarity with patients, patients' general condition, visible frailty, and patients' ability to manage at home. "Therapy assessment" and patients' engagement with therapy were also reported to be important in recognising high-risk patients. However, staff recognised that making clinical judgments was often difficult and that it might occur several days after admission potentially delaying specific interventions. Routine risk assessments carried out on admission to identify single healthcare needs included risk of malnutrition (completed for 85% patients), falls risk (95%), moving and handling assessments (85%), and pressure ulcer risk assessments (88%). These were not used collectively to highlight patients at risk of poor healthcare outcomes. Thus, patients at risk of poor healthcare outcomes were not explicitly identified on admission using routinely collected data. There is a need for an early identification of these patients using a valid measure alongside staff clinical judgment to allow timely interventions to improve healthcare outcomes

Reciprocal elucidation: a student-led pedagogy in multidisciplinary undergraduate research conferences

© 2016 HERDSA. There is no previous study of the benefits of attending a national multidisciplinary conference dedicated to undergraduate researchers, despite the growing number of such conferences internationally. This paper addresses the gap in knowledge of the learning gains from these conferences, and reveals a student driven learning process, a multidisciplinary signature pedagogy. It presents the results of 90 in-depth interviews with student conference participants conducted over three consecutive years of a multidisciplinary National Conference of Undergraduate Research (2012–2014). This paper uniquely captures the student voice on their perceived learning gains from this experience. The results reveal that some students co-create a pedagogy of Foucauldian reciprocal elucidation, through a sense of ‘unfinishedness’, allowing them to reflect on their own learning in the light of divergent perspectives, questions and frames of reference. Bidirectional exchange of ideas and insights enabled students to ask and answer questions that transformed each other’s thinking, allowing them to arrive at understandings they could not have achieved by themselves. The opportunity to present research in an authentic setting beyond disciplinary and institutional contexts developed students’ skills and confidence, giving additional value over and above the recognised benefits of engaging in research. The undergraduate research conference is framed as a threshold experience for the development of self-authorship. Significant implications for practice include supporting constructive dialogues between students and the creation of authentic and professional multidisciplinary contexts for sharing research

Tandem quadruplication of HMA4 in the zinc (Zn) and cadmium (Cd) hyperaccumulator noccaea caerulescens

Zinc (Zn) and cadmium (Cd) hyperaccumulation may have evolved twice in the Brassicaceae, in Arabidopsis halleri and in the Noccaea genus. Tandem gene duplication and deregulated expression of the Zn transporter, HMA4, has previously been linked to Zn/Cd hyperaccumulation in A. halleri. Here, we tested the hypothesis that tandem duplication and deregulation of HMA4 expression also occurs in Noccaea. A Noccaea caerulescens genomic library was generated, containing 36,864 fosmid pCC1FOSTM clones with insert sizes ~20–40 kbp, and screened with a PCR-generated HMA4 genomic probe. Gene copy number within the genome was estimated through DNA fingerprinting and pooled fosmid pyrosequencing. Gene copy numbers within individual clones was determined by PCR analyses with novel locus specific primers. Entire fosmids were then sequenced individually and reads equivalent to 20-fold coverage were assembled to generate complete whole contigs. Four tandem HMA4 repeats were identified in a contiguous sequence of 101,480 bp based on sequence overlap identities. These were flanked by regions syntenous with up and downstream regions of AtHMA4 in Arabidopsis thaliana. Promoter-reporter b-glucuronidase (GUS) fusion analysis of a NcHMA4 in A. thaliana revealed deregulated expression in roots and shoots, analogous to AhHMA4 promoters, but distinct from AtHMA4 expression which localised to the root vascular tissue. This remarkable consistency in tandem duplication and deregulated expression of metal transport genes between N. caerulescens and A. halleri, which last shared a common ancestor >40 mya, provides intriguing evidence that parallel evolutionary pathways may underlie Zn/Cd hyperaccumulation in Brassicaceae